Working Group Report: HIV/aids and Development

Brain drain and its effects on health service provision

Question: Brain drain and its effects on health service provision: an obstacle in achieving development goals?

A presentation was made on the topic discussing the situation of human resource crisis in health in Africa, with a particular focus on Ghana, and what has been done to turn the tide.

In the ensuing group discussion the facilitation, summed up the issues and highlighted the aspects of migration that affect the supply of human resources, including the following:

• Migration from public to private sector and (I)NGOs, • Migration from rural to urban areas within country, • Migration within a region (e.g. majority of health personnel in Botswana come from other African countries) and between regions • Move from health sector to other sectors (particularly in the context of international migration)

In addition, the impact of HIV/AIDS was mentioned as a major factor in loss of human resources. In high prevalence countries (15% or higher) one third of health personnel is lost due to HIV/AIDS.

In general it was felt that there is inadequate attention paid to health as an investment rather than a cost. The health worker crisis can only be addressed through action in the developed and the developing world through a combination of interventions that address both the pull and push factors in the short, medium and long term.

A study has been conducted on the underlying reasons for migration of health personnel and the results point to the following factors:

• Low salary, • Poor working conditions (work motivation), • Excessive workload, • Occupational hazards

With reference to these factors the following points were raised:

The experience from Ghana shows that a mixture of measures is needed to address the issue of low compensation. Their initial effort to cover the cost of extra duty hours through an allowance has been changed as it initially resulted in more people migrating out of the country after they had saved enough money for their travel costs. An alternative to this has been to increase the salaries 4-5 times for a more focused group of health workers (doctors, nurses and pharmacists only, not ancillary staff) by using debt relief. An extra allowance is paid for those working in disadvantaged areas.

Ghana has also experimented with “conditional migration” incl. withholding a proportion of migrants salary (by the employer) to be sent back to the government of the sending country for health sector related improvements such as development of training facilities etc. The argument in favour of this method was to that it allows the government to capitalise on the social responsibility of the migrants who before leaving the country have received education paid by tax income. Some members of the working group felt that such mechanisms may not be entirely transparent and did not see added benefit e.g. in relation to individual remittances. Another condition was to require proof of service in country of origin before processing the paperwork required for migration. This again was critized in the light of freedom of movement. In some countries new graduates are by law required to serve their country for a certain period after graduation. This condition can be filled only if a job offer can be made. However it does not stop migration as such, but may lead to loss of staff after they have gained a few years of work experience.

Education as a human resource development strategy requires a long time if we are to maintain and improve the quality of health services. Currently the speed at which the HIV pandemic is spreading and the speed of finding and implementing a solution for the human resource crisis are not in sync. Provision of ODA to cover the cost of quality education of medical staff in developing countries over and above national demand was suggested as one way for developed countries to pay for the actual cost of migrating health personnel. There has been some good experience in strategic, periodic and circular exchange of staff (within and between regions, two-way) as a means for human resource development.

Priority action for the EU and its member states would be to critically examine their national health systems in order to address issues that may function as pull factors. The system to analyse (global) health impact of EU policies should also be strengthened. A reference was made to ethical recruitment and whether national codes of conduct work in this respect. There were some doubts as to the applicability of these codes once the migrant has achieved permanent residence status/citizenship in the receiving country. Legislation on ethical recruitment is being prepared and its applicability is being reviewed in Norway.

General strengthening of the health system was seen as a key to improvement as opposed to vertical (illness specific) approach. In this regard some ideas were presented e.g. to allocate 50% of funding for HIV/AIDS to health system strengthening. In order to avoid competition between diseases, there is a need for “fresh new money” – possibly from domestic sources (e.g. reallocation of budget from defense to health), innovative funding schemes etc. It is also important that funding is allocated to cover all aspects of the HIV/AIDS pandemic (prevention, treatment, care and support). At the same time there is need to monitor effects of IMF and WB conditionalities (budget ceilings).

The HIV/AIDS pandemic and the response it requires (including effective delivery of the incoming aid) has revealed the chronic poor state of the health systems in developing countries. In order to deliver the response required by the HIV/AIDS pandemic, improved access to prevention and treatment for health care staff has been seen as a priority and necessary component of overall strengthening of the health system and a partial solution to the health sector human resource crisis.

In addition to the formal health sector the involvement and strengthening of community level human resources can be used as a way to fill the gap caused by loss of health personnel. Another, partially related, measure that can be applied both in developed and developing countries is (certified) task shifting (e.g. from doctors to nurses and from nurses to community health workers ) so that existing resources can be optimally used to get the best possible services, while other longer term measures are taken to increase the numbers of qualified health personnel. Intensive training should accompany these efforts to replace those who have left

Implementation of commitments and mainstreaming

Question: Implementing commitments and mainstreaming: a means to achieve development goals?

A question was raised concerning the definition of mainstreaming. There is a need for a clear working definition as there are many different notions about this concept. Can we regard it asd meaning the same as coherence? Mainstreaming can also be dangerous: HIV/AIDS might lose the exceptional response that it needs.

The need to see HIV/AIDS and the response to it as a cross-sectoral issue was emphasized. There was a reference to conflict resolution and the need to consider HIV/AIDS as part of the package during conflict, in transition and beyond.

The European Development Consesus was welcomed thanks to its reference to HIV/AIDS as an issue to be considered in all sectors. The Development consensus was seen as a common agenda and shared responsibility betw. The EC and member states. The Commission should be in a position to map and monitor coherent implementation of commitments.

The practicalities for ensuring that this happens requires a systematic way to ensure that HIV/AIDS is coherently included in all sectors as per the Development Consensus. The existing collaboration and coordination structures that exist within the EU (HIV/AIDS task force, HIV/AIDS think tank, inter-sectoral working group on HIV/AIDS) should be strengthened and well resourced to undertake the task of ensuring coherence. In the other working group a suggestion was made to appoint a Commissioner of Special Representative on HIV/ADS to ensure coherence with regard to HIV/AIDS in all EU policies.

In order to monitor implementation of commitments a set of appropriate indicators is needed. To track the level and effectiveness of funding for HIV/AIDS; to ensure that it does not disappear altogether in broader integrated programs.

Access to Treatment As the request to have the narrative report also ready at 13:00 came rather late, it was not possible to include discussions that ensued the last presentation made Tuesday morning concerning Acces to Treatment.

One of the key observations was:

LDC access to medicines to combat HIV and AIDS must not be subordinated to the trade interests of EU member states. The position of DG SANO and DG DEV must take precedence over DG Trade inside the Commission, and position of CODEV inside the Council.